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Healthcare Reform Overview: Changes and Impacts
Long Term Care Integration Project
December 13, 2013
Peter Shih, MPH Health Care Policy Administration
Healthcare Reform Overview:
Changes and Impacts
• Provide an overview of the Patient Protection and Affordable Care Act (PPACA)
• Medi-Cal: What is changing and what is staying the same
• Medicare: What is changing and what is staying the same
• Low Income Health Program
• County Medical Services
• County response to healthcare reform
Objectives
• Medi-Cal being expanded to new populations
• 1 in 6 San Diegans will now be on Medi-Cal (up from 1 in 8)
• California’s new health insurance exchange
• 1 in 9 San Diegans are projected to purchase products via exchange
Prevention
and Public
Health Fund
• Funds community and state prevention;
• Tobacco prevention; • Obesity prevention; • Access to wellness &
preventive services; • Behavioral health
integration; • Public health
infrastructure and training; and
• Research and tracking.
How does the PPACA translate in CA?
The Triple Aim
Better Health for the Population
Better Care for Individuals
Lower Costs per Capita
Medi-Cal Eligibility Expanded to Fill Coverage Gaps for Adults
Medi-Cal Eligibility in 2014 Extends to Adults ≤138% FPL*
Elderly & Disabled
*138% FPL =$15,856 for an individual and $26,951 for a family of three in 2013
Pregnant Women
Children Parents Adults
Medi-Cal Eligibility Today Limited to Specific Groups
Medi-Cal Expansion
Medi-Cal Today 2014 and Beyond Medi-Cal coverage for adults is
limited to:
Adults aged 65 and older
Persons blind or with disability
Adults who have at least one child in
the home that meets deprivation
requirements
Pregnant Women
Adults in Long term Care
Foster Youth to Age 21
Children Under 21
Most childless adults who are at or
below 138% of FPL will qualify for
Medi-cal.
Adults aged 65 and older
Persons blind or with disability
Adults who have at least one child in
the home that meets deprivation
requirements
Pregnant Women
Adults in Long term Care
Foster Youth to Age 26 if they were
enrolled in Medi-Cal at age 18
Children Under 21
Covered CA + Medi-Cal: The Coverage Continuum
MAGI Medi-Cal (Modified Adjusted Gross Income) (0-138%) FPL
Proposed Bridge Health Plan (139%-200%) FPL
Private Insurance (400% +)
APTC/CSR(200%-400%) FPL
Advanced Premium Tax Credit/Cost Sharing Reduction
No
n-M
AG
I M
ed
i-C
al
(AB
D, L
TC, e
tc.)
MAGI Medi-Cal Groups
• MAGI is the new methodology for determining household composition and family size by using countable income for tax purposes
MAGI Description Federal Poverty
Level
Childless Adults Individuals between 19 and 64 years of age
Up to 138%
Parents and Caretaker Relatives
Parents and caretaker relatives with a dependent child
Up to 138%
Children Infants and children under age 19
Up to 250%
Pregnant Women
Pregnant and post-partum women for pregnancy services or full scope benefits
0 - 138% (full scope)
139%- 200% (pregnancy
services only)
Non-MAGI Medi-Cal Groups
• Non-MAGI is the new term for the existing Medi-Cal programs that will not follow MAGI rules
• Asset tests are still required for these programs
Medicare and PPACA
• Medicare isn’t part of the Health Insurance Marketplace, so a Medicare beneficiary won’t need to do anything. You are considered covered if have Medicare.
• The Marketplace won’t affect one’s Medicare choices, and benefits won’t be changing.
• The Marketplace does not offer Medicare supplement (Medigap) insurance or Part D drug plans. For information on these programs, visit Medicare.gov or contact the Health Insurance Counseling and Advocacy Program (HICAP).
• Dual Eligibles a high priority for CMS o Medicare-Medicaid Coordination Office created by ACA
o With CMMI testing new approaches to care coordination
• California one of ~20 states participating o Goal: integrate Medicare, Medi-Cal, and Medi-Cal long-term services and
supports (LTSS) to create patient-centered coordinated care delivery that will improve quality while reducing fragmentation and cost
o MOU signed with CMS on March 27, 2013; CA one of 6 states to sign
o ~456,000 beneficiaries will participate
o Enrollment begins no earlier than April 1, 2014
• San Diego one of 8 counties participating o 4 health plans: Care First, Community Health Group, Health Net, and
Molina
o ~46,000 beneficiaries
Coordinated Care Initiative (CCI) – Cal MediConnect
Legal Permanent Residents
Legal California residents are eligible to apply for:
• Medi-Cal (0 – 138% FPL)
• Covered California insurance plans and tax credits (139 – 400% FPL)
Effective 1/1/14, Medi-Cal coverage will extend to newly qualified legal immigrant adults (residency less than 5 years) and eventually migrate to a plan in Covered California when ‘Wrap Program’ is established
Undocumented Immigrants
• Most eligible for Emergency or Limited Scope Medi-Cal only
• Not eligible for the Covered California plans
• Not subject to the individual mandate
• Young people DACA (Deferred Action for Childhood Arrivals) will be eligible for full scope Medi-Cal beginning January 1, 2014. The individual must be under age 31 as of June 15, 2012 and have an approved DACA application (see US Citizenship & Immigration Services website)
Low Income Health Program (LIHP)
• Created under California’s “Bridge to Reform” Medicaid Section 1115 Waiver to prepare for Medi-Cal expansion
• Enrolls uninsured adult county residents with incomes <133% FPL to provide medical care and limited mental health services
• Uses a network of local service providers 22 hospital sites (13 hospital organizations)
58 community health clinic sites (16 parent organizations)
20 mental health clinics
122 specialty groups, including more than 345 individual providers
• Enrollment has grown from 14,000 in July 2011 to more than 40,563 in October 2013
• All LIHP enrollees will transition to MediCal January 1, 2014
LIHP Transition
• LIHP Program ends December 31, 2013
• Projected 45,000 enrollees transitioning to Medi-Cal Managed Care on January 1, 2014
• 5 Medi-Cal Managed Care Health Plans in Healthy San Diego • Care1st Health Plan
• Community Health Group
• Molina Healthcare
• Health Net
• Kaiser Permanente
• Established Local Transition Team • Continuity of Care and Communication Workgroups to assure smooth
transition
• Healthy San Diego Health Care Options (HCO) staff will assist enrollees with education and health plan choices
County Medical Services (CMS) Program
• County Section 17000 Indigent Care obligation remains even after PPACA coverage expansion
• Active CMS participants have declined from >4,000 in July 2011 to ~2,000 as LIHP has grown
• CMS Program will continue to serve residents of San Diego who • Meet income eligibility requirements (0 – 350% FPL) and are not enrolled
in Covered California
• Missed Open Enrollment period and do not have a qualifying event
• Refuse to apply for Covered California
• Not willing to pay monthly premium
• HHSA Health Care Reform Committee established • Reviewing CMS Program for possible changes • Data analysis to forecast number remaining uninsured
• Key “call to action”: those without insurance should contact Covered California
• Outward-facing County website under development to include information on PPACA — what it does, what it does not do, & what the County’s role is
• Leveraging relationships with community partners funded by Covered California, the California Endowment, etc. for outreach and targeted communication
• Reaching out to Advisory Boards to ensure messaging efforts are aligned
Messages Being Communicated to the Public
• Actual enrollment in new coverage options unknown and hard to predict
• Processes for expanded Medi-Cal enrollment will be manual, not automated during first few months
• Funding for Medi-Cal administration being increased, while Realignment funds are decreased with coverage expansion
• Impact to existing programs (increase or shrinkage) • Unknown size and costs of County Medical Services
(CMS) program • Uncertainty surrounding immigration reform linked with
refugee needs
Risks and Unknowns Unknowns and Challenges
Integration of services and communication across service areas will be critical:
Finance and Legal
Risks and Unknowns HHSA’s Value Chain
Procurement: Program Contracts
INBOUND
LOGISTICS
Federal laws,
State mandates,
and County policies
and procedures
affect the services
we provide
PROGRAM
Staff
produce program
material enacting
laws, mandates,
and policies and procedures
OPERATIONS
Eligibility and
Support
staff evaluate
individuals for
benefits
OUTREACH
Information is
provided to
individuals through
health fairs,
libraries, FRCs, and
clinics
IT: (CalWIN, CalHEERS, AuthMed)
Strengths-Based HR Management
SERVICES
Assist individuals with
benefits (Medi-Cal
CMS) along with
Appeals and
CCHEA
Risks and Unknowns Implementation Timeline
Oct 2013 Nov 2013 Dec 2013 Jan 2014 Feb 2014 Mar 2014
LIHP program sunsets
Open Enrollment Period
ACA Implementation Begins
SDG CalHEERS Call Center GoLive
LIHP Conversion
Processing Center Phases
Call Routing
Warm Handoff
Delivery System Transformation in ACA
• Center for Medicare and Medi-Cal Innovation (CMMI) ₋ Test new payment and service delivery models
₋ Evaluate results and advance best practices
₋ Engage a broad range of stakeholders
• Community-Based Care Transitions Program (CCTP) ₋ San Diego Care Transitions Partnership: HHSA Aging and Independence
Services, Palomar Health, Scripps Health, Sharp Health, and UC San Diego Health System – 11 hospitals/13 sites
₋ Reduce 30-day all-cause hospital readmissions by 20% for almost 21,000 fee-for-service Medicare beneficiaries in 2 years
• California Coordinated Care Initiative (CCI) /Cal Medi-Connect ₋ San Diego 1 of 8 counties participating to create patient- centered
coordinated care for ~46,000 “dual eligibles”
₋ 4 health plans will integrate Medicare, Medi-Cal, and Medi-Cal Long Term Services & Supports (LTSS)
San Diego Public Health Grants
Community Transformation Grant (CTG)
• Support the reduction of tobacco use, increase healthy eating and activity, and reduce inequities
• Support the implementation of community prevention activities that have broad impact
• San Diego awarded a CTG in 2011 - $3.05 million/year for 5 years
Public Health Infrastructure and Training
• Advance health promotion and disease prevention at local level through information technology, workforce training, and policy development
• Build state and local capacity to prevent, detect, and respond to infectious disease outbreaks
• National Public Health Improvement Initiative – $1.1 million grant to San Diego over 5 years
Q & A
Aligning with by
Building Better Delivery System
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